DCMS members volunteer with FAME Medical in Tanzania: Part 2
Tuesday, August 13, 2019
Posted by: DCMS
Please enjoy the below update from DCMS members Dr. Todd Sack and Barbara Sharp following their service trip with FAME Medical in Tanzania. They spent two weeks touring Uganda and Rwanda, before heading to Tanzania where they worked for three weeks. To read about the first 3 days of their trip, click here.
Dr. Sack's Diary: Days 4-11
7/18 Thu: FAME Day 4: Esophageal Cancer:
Cool, cloudy day became sunny and 70 degrees. Barbara gave a lovely radiology lecture at Morning Report.
On ward rounds there were two patients with ascites for me to see, each with new ascites a few days after giving birth. The first has Hepatitis B, bacterial peritonitis, and is improving after antibiotics. I switched her to oral treatment. The second has pre-eclampsia, a complication of pregnancy. The fluid that I collected at bedside paracentesis suggested portal hypertension but Andrew Keaveny, my hepatology friend at Mayo Jacksonville, is looking into what should be the biochemical profile of ascites in pre-eclampsia.
I performed upper endoscopies for two men who cannot swallow. Both were found to have dreadful esophageal cancers. We lack the optimal endoscopy equipment that might open up the blockage to allow them to eat, but I did fully open one of them the following week using a Bougie, a technique developed by Moroccan physicians in the Middle Ages. Esophageal cancer is far more common here than in the US. Tobacco and alcohol are risk factors but there is also something in the diet and a study a few years ago found that the very hot tea consumed here, hotter than in most countries, might be a factor.
We gave a dinner party for four of the Tanzanian doctor plus our housemate, Winnie, with whom we celebrated her 29th birthday with a chocolate cake.
7/19 Fri: FAME Day 5: Brucellosis:
On ward rounds, we met a 1-year old baby with a hemoglobin of 2.1, a giant liver, and giant spleen, attributed to malnutrition. At the lunchroom they offer thick, white “maziwa mgando” out of a big plastic jug for 20 cents per glass. It is delicious buttermilk, as tasty as what my grandmother would give me when I visited her in Walnut Creek as a boy. There is a lot of Brucellosis (a serious bacterial infection) in the local herds so I won’t buy “maziwa mgando” very often again.
We saw an elderly woman with vomiting for six months in whom we feared cancer but Barbara found treatable SMA Syndrome on CT; a 53 year old tea picker with two days of low-grade cough, fever and arthralgias (likely viral); a 25 year old hotel housekeeper with no significant symptoms but wanting testing because her husband has a yellow penile discharge.
In the evening, there was a nice reception for volunteers Beth & Paul who leave tomorrow, held at the home of FAME’s Co-Directors Susan & Frank.
7/20 Sat: FAME Day 6: Anemias & Walk to Karatu:
It is our Peter’s 30th birthday! Cool, overcast morning that will warm up. The hospital has 4-5 empty beds this morning. On rounds is a 40 year old woman who walked in with chronic vaginal bleeding & the lowest hemoglobin I’d ever seen at 2.2, but for yesterday’s child who had 2.1 (normal is 13). Barbara later found benign uterine fibroids at ultrasound, so the woman is headed to a hysterectomy. A 1-year-old Maasai baby with severe heart failure is much better and ready to travel to Dar es Salaam to the public heart center but the father cannot afford the trip and is taking the child home. A woman is doing well after cholecystectomy for pigment stones. A 14-year-old boy is in his third day with high fever and mental confusion despite IV antibiotics. Oddly, his white blood cells are low and liver tests elevated so we added antibiotics to cover Brucellosis. He dies in the night. A man with a perforated gastric ulcer is heading home after successful surgery.
We took an hour-long walk on the dusty road down into Karatu. Along the way we talked with little kids 2-3 feet tall who jumped up and down with glee at seeing us. We walked around the market seeing its sacks of grain and lovely vegetables (everything here is organic as farmers cannot afford to buy chemicals). Barbara bought two bright fabrics, made in Tanzania, for tablecloths.
We cleaned up and took a taxi after dark to Gibb’s Farm, an elegant boutique safari hotel. This was delicious culture shock for us: Tanzanian octopus, Nile perch, local rabbit, & martinis of fine English gin.
7/21 Sun: FAME DAY 7: Hike to Ngila Coffee Estate:
Warm, sunny day. We slept until 10am, made breakfast frittatas, and at 11:30 set off on a four-hour hike down the red dirt road behind FAME and into the large Ngila Coffee Estate that backs up to the forest of the Ngorongoro Preserve. Ngila’s guard allowed us onto their shady road but cautioned us not to walk in the forest because of “dangerous animals.” We walked through the irrigated coffee fields and watched about 30 women at the coffee processing area as they turned over the piles of coffee drying in the sun on long trays. The sight of a thriving Tanzanian coffee estate certainly competes well with a Sonoma vineyard for orderly beauty.
We continued on a dirt road through large fields of maize, wheat, sunflowers & marigolds. We are not sure why someone is cultivating marigolds. Four children aged 5-12 walked by with huge bundles of firewood on their heads, obviously scavenging from the national park. This seemingly harmless practice is a great threat to the world’s “protected” tropical forests, forests that depend upon the decay of fallen limbs to maintain soils that easily erode during the rainy season.
After a mid-afternoon rest, we walked an hour into town to split a pizza and use the internet. Exciting was a caravan of 40 vehicles that sped through town bearing the Prime Minister who was here to dedicate a new tourism facility.
7/22 Mon: FAME Day 8:
At Morning Report, Barbara used the TV screen to teach us the interesting images from the past week. On ward rounds, we learned that a man who did well after his pneumothorax was treated with a chest tube chose to leave early over the weekend because he’d witnessed three patients die in his room.
In clinic, a man with an infection of his left salivary gland was given antibiotics; a 69-year-old man with suspected TB pneumonia is much better after two weeks of treatment.
7/23 Tue: FAME Day 9: Endoscopies:
I gave a lecture on the management of acute pancreatitis that was well-received. The hospital is only a bit over half full so there was more time for teaching on ward rounds. We discussed ascites associated with eclampsia, hemolytic anemia in an infant with a blood type different than the mother’s, hypertension management, and aspects of post-surgical care.
I performed a successful endoscopic dilation on a man who has only been able to swallow liquids for months and diagnosed at endoscopy an advanced vallecular cancer on a 73 year old Maasai man. His son wore a huge dagger on his belt making me reluctant to explain his father’s poor prognosis.
In clinic was a 29-year-old Maasai woman, nursing a robust two year old, with a large and infected nasal polyp that we’ll remove by surgery next week, and a woman with Hepatitis B and normal liver blood tests. Pharmaceutical companies are making so much money selling their hepatitis medicines at ridiculous high prices to Americans that they won’t lower their prices to make their curative regimens available to Africans.
Tiring day. Around 4:30pm, I sat upon a chair containing a towel soaked with my patient’s sputum. I elected to go home for a shower, clean clothes and a beer on our porch watching the sun set over the hills of the Ngorongoro forest a mile away.
7/24 Wed: FAME Day 10: Alcohol:
After rounds, I endoscoped a 75 year old man who had vomited blood. I found a small Mallory-Weiss lesion (an esophageal tear caused by vomiting) and portal hypertensive gastropathy (poor blood flow in the stomach caused by liver disease). We had a long talk about alcohol. There is so little to do for people to entertain themselves in the villages that we wonder why alcoholism isn’t universal.
An obese woman came from four hours away for chest pain that turned out to be rib pain radiating from her back. My far bigger concern is that she stopped her diabetes medicines two years ago and is unwilling to reconsider that choice. A 48-year-old Maasai man came with vomiting and weight loss; we found amoebiasis (a bacterial infection) and new HIV.
FAME is in the final stages of building a handsome new building for maternity care, including delivery rooms. Exciting today is the arrival from the U.S. of a shipping container stuffed with donated supplies after being held by customs officials here for nine months. Infant and maternal mortality are huge problems. These drive parents to have large families as insurance against losing several. One of FAME’s great achievements is to have lowered dramatically the mortality of mothers from giving birth.
Several of us taxied down to Happy Days, a small cafe with a nice chicken curry.
7/25 Thu: FAME Day 11: Tribes:
Barbara gave an interesting talk demonstrating diseases that can be seen by abdominal CT scan. On Morning Report, we learned of a difficult emergency cesarean section for a woman whose uterus had ruptured at home. She needed six or seven transfusions during a harrowing operation but was discharged a few days later.
At lunch, the gardener took us on a tour of his fabulous vegetable garden that supplies the vegetables for the 130 employees fed each midday.
I saw in clinic a 35-year-old watchman with chronic migraines. His CT scan by Barbara was normal so I prescribed amitriptyline and ibuprofen, which is all that the pharmacy has for this. He will return in September to meet with a group of neurologists who come twice a year from the University of Pennsylvania (they saw 425 patients with their April visit). I saw a child with mild flu, a 75 year old Dutch tourist who fell and needed a shoulder x-ray, a four year old girl who needed a head CT (normal) as she hasn’t talked yet, and a woman with chronic right groin pain for whom I prescribed ibuprofen as the pelvic sonogram was fine.
Tanzania has become a cultural melting pot. The government requires us to track each patient’s tribal identity. My patients in clinic today were from six different tribes: Maasai, Sukuma, Nyiramba, Iraqw, Pare, & Meru. Mixing began in the late 1960’s when President Nyerere tried to push people together into socialistic communal farms. That failed, of course, but Tanzanians say that Nyerere’s best legacy may be this peaceful tribal migration and intermarriage that now is both common and accepted.
We had dinner with FAME Co-Directors Susan Gustafson & Dr Frank Artess.
7/28 Sun: FAME Day 14: Gibb’s Farm with Dr. Gabriel:
Cool sunny day. Dr. Gabriel Paul, FAME’s Chief of Staff, and we drove 15 minutes to lunch at Gibb’s Farm. This is a very expensive boutique hotel in an elegant colonial-era manor house. Brunch was fabulous (just $28 pp. for FAME volunteers), on the terrace above the Ngila Coffee Estate and with a view across the valley to FAME.
Gibb’s is owned by an American who has also a travel agency in the US, two dozen safari vans, and several other luxury lodges. Certainly many Tanzanians are employed by all these but we sensed that much of the cash from these lavish safaris never makes it to Africa. This, and the lower prices, are why we try to use locally-owned travel companies and lodges.
After lunch, we toured the beautiful gardens and large farm that provides vegetables, eggs, milk, meat, goat cheese and coffee to the hotel. Dr. Gabriel, who grew up growing coffee with his dad on their small farm a few hours away in Moshi, taught us about growing coffee.
He dropped us off in town where we had tablecloths made at Edna’s sewing shop, bought onions for a dinner we’ll make Tuesday, and wandered about the dusty shopping area. I made note of the name of Barbara’s favorite shop for colorful Tanzanian kitenge cloth, Tango Shop, that was closed today. We had a nice curry dinner at the Lilac Cafe and took a tuk-tuk home ($1.20).
To learn more about FAME Medical, click here.